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MALTREATMENT INVESTIGATION MEMORANDUM Minnesota Statutes, section 626.557, subdivision 1 states, “The legislature declares that the public policy of this state is to protect adults who, because of physical or mental disability or dependency on institutional services, are particularly vulnerable to maltreatment.”
License Number and Program Type: 1080538-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Scott Broady 651-431-6557 Suspected Maltreatment Reported: Allegation one: It was reported that a staff person (SP1) grabbed a vulnerable adult (VA) by the neck. Allegation two: It was reported that a staff person (SP2) hit the VA. Date of Incident(s): Between October 12 and 20, 2022 Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (b), and Minnesota Statutes, section 626.5572, subdivision 15, and subdivision 2, paragraph (b), clause (1): Conduct which is not an accident or therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to: hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult. Summary of Findings: Pertinent information was obtained during site visits conducted on November 9 and 10, 2022; from documentation at the facility and law enforcement records; and through interviews conducted with the VA, five facility staff persons (SP1, SP2, and P1-P3), and the VA’s family member/guardian (FM). The facility was a single level with a finished basement. The main level included two common areas, a kitchen, and living room. Off of the main common room there was a hallway that led to three bedrooms and a bathroom. The first bedroom on the left was a consumer’s (C’s) bedroom with the VA’s bedroom being at the end of the hallway. The VA’s support plans stated: · The VA’s diagnoses included autism and obsessive compulsive disorder. · The VA was able to express his/her wants and needs verbally. · The VA had history of hitting, pushing, kicking, and throwing objects at others. Staff persons were to intervene by stepping in between the VA and other persons involved. · The VA enjoyed spending time with his/her family, working with his/her hands, and indoor and outdoor activities. Allegation one: It was reported that SP1 grabbed the VA by neck. The incident occurred in the doorway and the hallway immediately outside of the C’s bedroom. A law enforcement report completed by two law enforcement officers (LEO1 and LEO2) stated: · On October 18, 2022, LEO2 met with the FM who had called 9-1-1. The FM stated that s/he had concerns about the VA and the facility as the VA told the FM that over the weekend SP1 grabbed the VA around the neck causing the VA to not be able to breathe. The FM said that the VA would not understand that putting hands around a person neck would cause them not to breathe unless it happened to him/her. The FM stated that there were marks on the VA’s neck that were similar to finger nail marks. · Later on October 18, 2022, LEO1 went to the facility and talked to a supervisory staff person (P4). P4 told LEO1 that s/he was recently told about the concern by the FM. P4 told LEO1 that s/he asked the VA when the incident occurred and the VA said two weeks ago during an incident where the VA shut him/herself in the C’s bedroom. P4 told LEO1 that s/he talked with SP1 and SP1 denied that the incident occurred. P4 showed LEO1 photos that s/he took of the VA’s neck area and P4 believed that the marks on the VA’s neck were “razor bumps” from shaving.
· On October 19, 2022, the FM and the VA met with LEO1 for an interview. LEO1 asked the VA to point to the area of the neck which hurt and the VA pointed to two areas of his/neck. The first area was at front of the neck area and there appeared to be two or three small dots that looked “irritated.” The second area there was a mark on the left side of the VA’s neck that looked like a vertical scar that appeared to be healed. The FM stated that the VA saw a dermatologist and they said that the marks on the VA’s neck were from an “assault and were not natural.” LEO1 requested documentation of that and the FM said that s/he would get that information for LEO1 at a later time. · Due to the VA’s cognitive disorder, LEO1 was going to wait to interview the VA, but then asked the VA, “Tell me what happened.” The VA responded that s/he walked into the C’s “door” and now s/he could not breathe from his/her throat. The FM then asked the VA, “Who did that?” The VA responded SP1. The FM then asked, “How did [s/he] grab your throat?” The VA responded that s/he grabbed the VA’s throat and would not let go. The VA then said SP1 and P1 did that. The VA also said that other people who live at the facility did that. The FM told the VA that, “SP1 grabbed your throat.” The VA then made a pinching motion to his/her neck and said that s/he did it with his/her “claws.” The FM provided information to this investigator that was consistent with the information in the law enforcement report. Photographs of the VA’s neck taken on October 17, 2022, by the FM showed marks on the VA’s neck that were consistent with the description in the law enforcement report. In the facility’s internal review report, the VA stated that nothing happened to the back of his/her neck but pointed to the front of his/her neck and made a pinching motion at his/her throat. The VA said that SP1 did that when the VA was going into the C’s bedroom. The VA then said that SP1, P1, P2, and P3 all did that. When questioned about that statement, the VA “switched back” to only SP1 did that. When asked what SP1 did to him/her and if his/her hands were on the VA, the VA replied, “Just my throat not the back of my neck.” On November 10, 2022, this investigator interviewed the VA. The VA initially said that no one touched his/her neck, but then said that SP1 choked him/her because s/he went into the C’s room. The VA stated that SP1 choked him/her in a chair in the kitchen. The VA also stated that SP1 hit him/her. Documentation completed by P2 stated that on October 12, 2022, the VA tried to hit a staff person and that staff person moved out of the way. The VA then locked him/herself in the C’s bedroom. Another staff person was able to calm the VA and then the VA went in the kitchen and hit a staff person in the head while their back was turned. In the facility’s internal review report, in interviews with LEO1, and in interviews with this investigator, SP1, P1, P2 provided the following consistent information about the incident: · On October 12, 2022, around dinner time, P1 was going to the C’s bedroom and the VA ran to the C’s bedroom to try to get in the C’s bedroom. While in the C’s bedroom and in the hallway immediately outside the VA’s bedroom, P1 intervened with the VA. P2 and SP1 witnessed the incident. Another staff person (P5) was working but did not witness the interactions between the VA and P1. After the VA left the C’s bedroom, the VA hit P2 in the kitchen. · SP1 was present during the incident, but was not near the VA or involved in any interactions with the VA. SP1, P1, and P2 provided the following information to LEO1: · SP1 stated that when P1 and the VA went to the C’s bedroom, the VA became upset and “attacked” P1. SP1 ran toward the altercation and saw P1 restrain the VA while the VA “was on [his/her] stomach.” The VA had his/her head turned and was trying to bite P1. At that point, P1 was holding the VA on the back of the VA’s neck area. The VA yelled that s/he could not breathe and P1 let go of the VA. SP1 said that s/he never touched the VA’s neck area and did not know why his/her name “was brought up.” · P2 stated that s/he saw P1 go toward the C’s room as the VA tried to go into the VA’s room. The VA was able to get into the C’s bedroom and when s/he came back out, the VA “attacked” P1. The VA attempted to bite and head butt P1 and P1 was holding the VA back so s/he could not head butt him/her. After the incident, the VA said that SP1 hit him/her, but SP1 was not involved in the incident. P2 never saw the VA on the ground or hear the VA say that s/he could not breathe. P2 did not see anyone place their hands on the VA’s neck. · P1 stated the VA tried to get into the C’s room and P1 tried to hold the door so the VA could not get in and the VA was able to get into the room. P1 said that s/he did not have any physical altercation with the VA other than trying to prevent him/her from getting into the C’s bedroom. P1 did not place his/her hands around the VA’s neck area and did not any see anyone else place their hands on the VA’s neck area. SP1, P2, and P2 provided the following information in the internal review report: · SP1 stated that s/he was in the lower level and came up and saw the VA and P1 “scuffling” by the C’s bedroom door. Most of the VA’s body was in the C’s room and the VA was leaning out trying to bite P1 who was in the hallway. The VA was lower to the ground “almost on” his/her knees trying to grab P1’s leg to bite P1. P1 placed both his/her hands on the back of the VA’s neck pushing his/her head to the side away from P1’s leg. At one point the VA said, “I can’t breathe.” P1’s contact with the VA lasted about 10 seconds. SP1 said that P1 was not being aggressive as s/he was trying to get the VA away from his/her leg. SP1 never saw any marks on the VA’s neck. · P2 stated that the VA pushed his/her way in the C’s bedroom and shut the door. P2 went and tried to talk to the VA and the VA started swearing. P2 then told P1 that they should just be quiet and maybe the VA would think they were gone and open the door. The VA opened and closed the door once but then opened it again and at that point, the VA tried to head butt P1. P1 blocked the VA with his/her hands to the back and then the VA “threw” him/herself on the ground and yelled out, “[SP1], you hit me you pushed me.” P2 told the VA that SP1 was not near him/her but also added that the VA mixed up names. P2 said that no staff persons had their hands on the VA and no one was near the VA’s neck including P1. When the VA calmed down, P2 looked over the VA did not see any marks except maybe a scratch on his/her face from when s/he threw him/herself on the ground. · P1 stated the VA pushed past P1 and went into the C’s bedroom. P1 then sat in the living room to “catch his/her breath.” At that time, SP1 and P2 were in the kitchen. The VA was in the C’s bedroom for three to five minutes. P1 did not see SP1 or the VA have any interactions that evening. In a subsequent interview, P1 stated that P1 held the door and never held the VA. P1 never put his/her hands on the VA or tried to block the VA from getting to him/her. The VA was not trying to bite P1. SP1, P1, and P2 provided the following information in an interview with this investigator: · SP1 stated that the VA hit P1 and P1 went into a “defensive posture.” The VA then was on the floor and tried to bite SP1’s leg. P1 applied pressure on the VA’s neck with both arms around the VA’s neck. P1’s hands were on back of the VA’s neck pushing the VA’s head away as the VA pulled P1’s leg toward him/her to bite it. P1 had his/her hands on the VA’s neck for 5 to 10 seconds trying to get away. P1 was able to go backwards and get his/her leg away from the VA and then put his/her body weight on the VA. The VA then got up and went into the C’s bedroom. · P2 stated that P1 did hold the VA’s wrists to prevent the VA from hitting him/her. P2 said that P1 did not hold the VA on the floor and no staff persons choked the VA or had their hands near the VA’s neck. · P1 said that the VA forced his/her way past P1 into the C’s bedroom. After the VA got by P1, P1 went and sat in the living room. P1 stated that other than the VA pushing P1 to get past him/her, P1 did not have any other physical contact with him/her. P1 was never involved in a restraint of the VA. P1 did not have contact with the VA’s throat. P1 did not see anyone else choke the VA. P1 was not aware of any marks on the VA’s neck. The facility internal review report included the following information: · P4 stated that the FM took the VA to a dermatology appointment and the paperwork from the appointment received by facility did not say anything about an allegation or marks on the VA’s neck. · P3, a supervisory staff person, stated that s/he never got a call from any staff person on October 12, 2022. Several days later, P4 sent P3 a picture of a bump on the VA’s throat. P3 described it as looking like a razor bump. P3 did not see any other marks on the VA. P3 never heard anything about SP1 doing anything to the VA and the VA did not mentioned anything to P3. Later, P3 was told that SP1 was not near the VA during the incident and that after the VA hit P2 in the head. P3 never had concerns about SP1’s interactions with consumers. · The VA had a history of “false reporting.” (Which was also stated the VA’s support plan.) P3 provided information to this investigator that was consistent with the information in the internal review report. Facility documentation showed that SP1, P1, and P2 each received training on therapeutic intervention and on the Reporting of Maltreatment of Vulnerable Adults Act. Facility documentation showed that SP1 and P2 each received training specific to the VA prior to the incident. P1 stated that prior to the incident, s/he received training specific to the VA (the facility could not located documentation of P1’s training specific to the VA so after the incident they provided P1 training again and documented the training). Conclusion allegation one: On October 12, 2022, there was an incident where the VA went into the C’s bedroom. Although the VA was consistent with saying that SP1 choked him/her, there was no information from staff persons that SP1 was other than a spectator to the incident and there was no information that SP1 had physical contact with the VA. Information instead showed that P1 was the staff persons who interacted with the VA when the VA went into the C’s bedroom. SP1 provided inconsistent information to LEO1, in the internal review, and to this investigator as to the positioning of the VA and P1 during the incident. SP1 told LEO1 that P1 restrained the VA while the VA “was on [his/her] stomach” with P1’s hands on the back of the VA’s neck while the VA’s head was turned attempting to bit P1, SP1 told the facility that the VA was almost on his/her knees when P1’s hands were on the VA’s neck, and P1 told this investigator the VA was on the floor when trying to bite P1 and that after P1 let go of the VA’s neck, P1 was able to get his/her leg away. As P1 tried to get away from the VA, s/he put his/her body weight on the VA and the VA then got up and went into the C’s bedroom. P1’s and P2’s descriptions of what happened differed from each other, but neither were consistent with what SP1 said happened. P2 said that P1 held the VA’s wrists to protect him/herself, otherwise P1 did not restraint the VA and never had his/her hands near the VA’s throat. P1 said that other than the VA pushing past him/her, s/he did not have any other contact with the VA. No one saw any marks on the VA’s neck after the incident. Photographs taken of the VA’s neck several days after the incident showed some marks, but it was unclear what the marks were from. Despite the VA being consistent that SP1 choked him, information from staff persons showed that P1 was the only staff person who had physical contact with the VA. With the conflicting information as to the nature of P1’s physical contact that s/he had with the VA, it was not determined whether P1 had physical contact with the VA and if so what the physical contact was. Therefore, was not preponderance of the evidence whether P1 or SP1 engaged in non-therapeutic conduct which would be expected to cause the VA physical pain or injury. It was not determined whether physical abuse occurred (conduct which is not an accident or therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to: hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult). Allegation two: It was reported that SP2 hit the VA. Documentation completed by SP2 stated that on October 20, 2022, at dinner time the VA was in the kitchen getting “edgy” about the food. The VA stood in the way to prevent another consumer get into the kitchen. The VA said that SP2 hit him/her even though at that the time, SP2 had his/her back to the VA. The facility first found about the incident from the above documentation. At that time, the facility completed an interview review of the incident which provided the following information: · SP2 said that s/he was cooking dinner and the VA came in the kitchen and said that s/he did not want to eat a salad. SP2 told the VA that s/he did not have to eat it and then turned his/her back to the VA at which time the VA said, “You hit me.” SP2 thought that the VA was talking about someone else. Another staff person (P6) said to the VA, “No one is hitting you.” SP2 then turned around and asked the VA who was hitting him/her and the VA told SP2 that s/he did. SP2 told the VA that s/he did not hit him/her. SP2 documented the incident because s/he wanted to make sure that it was documented that the VA was saying things that were not accurate. · P6 stated that s/he was in visual range of the kitchen the entire time and could see SP2 and the VA. As SP2 was getting something out of the oven, the VA said that SP2 hit him/her. P6 told the VA that s/he was there and no one hit the VA. P6 said that SP2 never hit the VA. Two other staff persons were working (P7 and P8) but P6 was not sure if they witnessed the incident. · P7 stated that s/he was around the kitchen area but stepped out and then heard P6 tell the VA, “Oh no [the VA], I’m sitting right here. No one hit you.” P7 never saw P6 hit the VA. · P8 stated that s/he heard the VA say, “You hit me.” P8 looked at P6 and P6 right away said, “No one did that, I’m right here. SP2 turned around and said, “Are you talking about me?” SP2 sounded “confused.” · The VA stated that no one hit him/her. The VA was then asked if s/he told someone that s/he was hit by a staff person and the VA said, “No one hitting me, I said no one hitting me.” The FM stated that after s/he heard about the allegation (s/he heard that a staff person hit the VA’s head), s/he asked the VA if anyone hit him/her in the head and the VA said no. This investigator asked the VA if a staff person hit him/her, the VA initially replied I do not know and when this investigator asked if a staff person ever did anything like that, the VA said that SP1 did that. SP2 told this investigator information that was consistent with the information in the internal review report. SP2 stated that s/he documented what the VA said so the VA would not say something to other people that was not written down. SP2 stated that s/he did not hit the VA. Facility documentation showed that SP2 received training on the Reporting of Maltreatment of Vulnerable Adults Act and training specific to the VA. Conclusion allegation two: On October 20, 2022, SP2 stated that while his/her back was turned to the VA, the VA told SP2 that SP2 hit him/her. P6 who witnessed SP2 and the VA’s interactions in the kitchen said that SP2 did not hit the VA. P7 and P8 each heard at least part of the incident and their information was consistent with SP2 and/or P6. After the incident, when the VA asked for the internal review, by this investigator, and by the FM, the VA never said that SP2 hit him/her. Given the above, there was a preponderance of the evidence that SP2 did not hit the VA. It was determined that physical abuse did not occur (conduct which is not an accident or therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to: hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult). Action Taken by Facility: The facility completed an internal review of allegation one and determined that their policies and procedures were adequate and followed. The facility completed an internal review of allegation two and determined that their policies and procedures were adequate, but not followed in that SP2 did not report the allegation immediately. SP1 and SP2 were each temporarily removed from working at the facility and staff persons received retraining on the Reporting of Maltreatment of Vulnerable Adults Act. Action Taken by Department of Human Services, Office of Inspector General: Although prior to the incident, the facility did not have documentation of P1’s training specific to the VA, because P1 said that prior to the incident s/he received that training and the facility retrained P1 and documented the training prior to the completion of the investigation, no Correction Order will be issued.
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